Continuous Improvement and the Expansion of Quality Measurement THE STATE OF HEALTH CARE QUALITY 2011

What’s New Since Last Year PPOs Catching Up Improvement Over Time Building a Value Agenda Overview

We know about the quality of care of 118 million Americans

Are parents with commercial insurance afraid vaccines cause autism? Follow-up to Key Finding Last Year: Childhood Immunization Drop in Commercial Plans

Follow-up to Key Finding Last Year: Childhood Immunization Drop in Commercial Plans

Follow-up to Key Finding Last Year: Childhood Immunization Drop in Commercial Plans…no real change

HMO and PPO Members Who Rate Their Plan 9 or 10 – Commercial

9 PPOs Catching Up

HMOs and PPOs perform comparably on many measures

HMOs and PPOs are Comparable: Asthma Measures – Commercial 2010

HMOs and PPOs are Comparable: Asthma Measures – Commercial 2010

HMOs and PPOs are Comparable: Select CAHPS Measures – Commercial 2010

HMOs and PPOs are Comparable: Select CAHPS Measures – Commercial 2010

HMOs and PPOs are Comparable: Eye Exams for Diabetics – Medicare (Star Ratings Measure)

HMOs and PPOs are Comparable: Eye Exams for Diabetics – Medicare (Star Ratings Measure)

HMOs and PPOs are Comparable: Cardiovascular Care – Cholesterol Screenings Medicare (Star Ratings Measure)

HMOs and PPOs are Comparable: Cardiovascular Care – Cholesterol Screenings Medicare (Star Ratings Measure)

19 Improvement Over Time

Improvement Over Time: Momentum for “Million Hearts”

Improvement Over Time: Momentum for “Million Hearts”

Improvement Over Time: Colorectal Cancer Screening – Commercial HMOs

Improvement Over Time: Colorectal Cancer Screening – Commercial HMOs

Improvement Over Time: HbA1c Screening for Diabetics – Commercial HMOs

Improvement Over Time: HbA1c Screening for Diabetics – Commercial HMOs

Improvement Over Time: Attention for Nephropathy for Diabetics— Commercial HMOs

Improvement Over Time: Attention for Nephropathy for Diabetics— Commercial HMOs

Improvement Over Time: Childhood Immunization – Medicaid

Improvement Over Time: Childhood Immunization – Medicaid

30 Building a Value Agenda

Population perspective - data on overall patterns of service use, quality of care Payment leverage Control over benefit design to reinforce incentives for enrollees Provide case management services Building a Value Agenda: Use Insurers’ Strengths to Become “Market Makers”

Lead or sponsor – Patient-centered medical homes (PCMH) – Accountable care organizations (ACO) Encourage medical practices to adopt and use health information technology Partner with practices to analyze data and improve care patterns Building a Value Agenda: Foster Delivery System Reforms

Use cost sharing to “nudge” people to use high-value services – Chronic care services – Maintenance medications Raise cost sharing for services with less benefit Reward use of decision aids to engage and inform patients about options Building a Value Agenda: Design Pro-Value Benefits & Coverage

Plans have enormous amounts of data and know how to turn data into information Can model transparency for other entities to emulate (e.g., medical practices) Bring a population view to managing care across settings Building a Value Agenda: Use Claims, Enrollment, Patient and Medical Records Data

Use plans’ wide geographic reach to build networks for purchasers seeking multi-state coverage Use cost sharing to steer patients to high- value hospitals & providers Report to consumers about providers’ value Building a Value Agenda: Assemble the Network

Use plans’ unique access to consumers to engage them in their own care Use health risk appraisals, wellness & health promotion to “reach people where they are” Encourage use of decision aids that help patients become informed partners in their own care Building a Value Agenda: Activate Patients

Guest Speakers Peter Briss, MD, MPH Medical Director, National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention John D. Bennett, MD, FACC President and CEO CDPHP Health Plan Laurel Pickering, MPH President and CEO Northeast Business Group on Health John Santa, MD, MPH Director Consumer Reports Health Ratings Center Guest Speakers

Continuous Improvement and the Expansion of Quality Measurement THE STATE OF HEALTH CARE QUALITY 2011

Heart disease and stroke are leading killers in the U.S. Cause 1 of every 3 deaths More than 2 million heart attacks and strokes occur every year; 800,000 die – Leading cause of preventable death among people <65 Treatment accounts for about $1 of every $6 spent on health care Accounts for the largest single portion of racial disparities in life expectancy

Clinical prevention Focus on ABCS Improving management of ABCS can prevent more deaths than other clinical preventive services Increasing utilization of these simple interventions could save more than 100,000 lives a year – Patients reduce risk of heart attack or stroke by taking aspirin as appropriate – Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among high-risk patients – Even brief smoking cessation advice from clinicians doubles likelihood of successful quit attempt – use of cessation medications increases quit rates further

41 Status of the ABCS: National Averages Aspirin People at increased risk of cardiovascular disease who are taking aspirin 47% Blood pressure People with hypertension who have adequately controlled blood pressure 46% Cholesterol People with high cholesterol who have adequately controlled hyperlipidemia 33% Smoking People trying to quit smoking who get help 23% Source: MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors --- United States, 2011, Early Release, Vol. 60

Improvement Over Time: Momentum for “Million Hearts”

Controlling High Blood Pressure: HEDIS Data: Commercial HMOs

Helping Smokers to Quit: HEDIS Data: Commercial HMOs

Controlling Cholesterol: HEDIS Data: Commercial HMOs

Best Performing Plans Have Achieved Significant Success Approximately 70-80% performance in controlling high blood pressure – Including some Medicaid plans Approximately 70-80% control of high cholesterol in people with cardiovascular disease Approximately 60-70% control of high cholesterol in people with diabetes Approximately 90% performance in advising smokers to quit

Poorest Performing Plans Have Much Room For Improvement – Approximately 30-50% performance in controlling high blood pressure – Approximately 30-50% performance in controlling high cholesterol in people with cardiovascular disease – Approximately 20-40% performance in controlling high cholesterol in people with diabetes Even lower in some Medicaid Plans – Approximately 60-70% performance in advising smokers to quit

What is Million Hearts? Goal: Prevent 1 million heart attacks and strokes over the next 5 years Engage public and private sector partners in a coordinated approach to: – Reduce the number of people who need treatment – Improve the quality of treatment for those who need it – Maximize current investments in cardiovascular health

Key components of Million Hearts Clinical Prevention – improving care of the ABCS through: – Focus – simplify and align quality measures; emphasize importance of improved care of the ABCS – Health IT – use electronic health records to improve care and enable quality improvement through clinical decision support, patient reminders, registries, and technical assistance – Care innovations – team-based care, interventions to promote medication adherence Community prevention – reducing the need for treatment through: – Prevention of tobacco use – Improved nutrition – decrease sodium and artificial trans fat consumption

What can be done In the medical system Health care providers – Focus on prevention of heart disease and stroke; improve care of ABCS; use health IT, including decision supports and registries, to drive quality improvements Pharmacists – Monitor medication refill patterns; engage doctors and patients in managing health Insurers – Include ABCS in performance measures; collect and share data for quality improvement; empower consumers Individuals – Take aspirin, if appropriate; take blood pressure and cholesterol medications as prescribed; if you smoke, quit

What can be done In the community Retailers – Offer blood pressure monitoring and educational resources; focus on improving ABCS care in retail clinics Government – Support community and systems transformation to reduce tobacco use and improve nutrition, including smoke-free policies and food procurement standards; provide data for action; expand coverage for the uninsured Foundations – Support consumer and provider outreach and education Advocacy groups – Monitor progress toward goal and promote actions that prevent heart attacks and strokes

52 About CDPHP ®  Physician-founded and guided health plan  Serves more than 350,000 members in 24 counties throughout New York.  Products include: HMO, PPO/EPO, self- insured, and all government programs offered in New York.  Several CDPHP ® health plans have again placed among the top health plans in New York state, according to the NCQA’s Health Insurance Plan Rankings.

53 NCQA’s Health Insurance Plan Rankings Among our top accomplishments: CDPHP Select Plan (Medicaid) is the top-ranked plan in New York state (and #5 nationally), according to NCQA’s Medicaid Health Insurance Plan Rankings, CDPHP Medicare Choices HMO remains ranked #2 in New York state (and #16 nationally), according to NCQA’s Medicare Health Insurance Plan Rankings, CDPHP HMO was ranked #2 in New York state (and #22 nationally) and CDPHN HMO/POS was ranked #3 in New York state (and #27 nationally), according to NCQA’s Private Health Insurance Plan Rankings, In addition: CDPHP Universal Benefits, ® Inc. PPO is the #6 PPO plan in the nation (ranked #40 nationally among private health plans) and CDPHN PPO is the #7 PPO plan in the nation (ranked #45 nationally among private health plans), according to NCQA’s Private Health Insurance Plan Rankings,

The State of Healthcare Quality 2011: A Purchaser and Coalition Perspective Laurel Pickering, MPH President & CEO A Presentation for NCQA October 13, 2011 Washington, DC

55 NEBGH  Business coalition covering NY, NJ, CT and MA  Members are large and mid-size, national self- insured companies  American Express, Goldman Sachs, Thomson Reuters, CBS, Pitney Bowes, Bloomberg LLP, City of New York, Con Edison, etc.  One of about 60 coalitions around country

56 Employers Have Woken Up Focused on the health of employees Recognize that this is the foundation for achieving lower health care costs and having more productive employees Taking aggressive steps to manage health of employees Current FFS, uncoordinated system doesn’t deliver on new goals of improved health and value Achieving greater value in all dimensions is imperative Employers are relying on health plans to do much of the “heavy lifting”

57 High Expectations of Plans Identify members that need intervention Get them into a program Engage the member Change the member’s behavior Engage and hold the provider accountable Promote transparency Pay claims and administer plan

58 NCQA is Critical to Employers’ Efforts Provides a standard set of measures on prevention and disease management Requires a rigorous process to be accredited Setting the standards on new delivery models Keeps reminding of us where we are and where we need to be

59 How do we hold plans accountable? eValue8 – National RFI for health plans sponsored by National Business Coalition on Health – Results are scored – NEBGH and customers meet with plans to review results – Encourage plans to participate in collaborations – NCQA accreditation and HEDIS measures form the foundation of eValue8

60 What do plans need to do? Collaborate – Plans need to collaborate to influence and incentivize providers to improve value and create new models of care delivery – NEBGH brings together competing plans and other stakeholders to work on new payment models and align incentives to drive improvement Aggregate – Plans need to aggregate data to get a more accurate picture of provider performance – NEBGH is aggregating health plan HEDIS data in NJ and sending reports on performance to individual PCPs Transparency – Plans need to make cost and quality information publicly available (or at least available to members) Engage members to capitalize on all of the above

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